Effective team working to improve diabetes care in older people

Clinical care has become more complex and more specialised; populations are ageing and people are living longer with multiple comorbidities, so increasingly need to access health and social care. Diabetes management and care of older people is presenting challenges to DSNs, who are responsible for planning their safe discharge from hospital. This increasing demand is stretching resources to the extent that services are fast becoming unsustainable.

Team working has been shown to improve patient safety, reduce waste, make services sustainable and improve staff retention, while improving patient and staff satisfaction. In the older population where more agencies are involved in the care of the individual, team working has the potential to improve care, making it safer, more effective and sustainable, while reducing duplication and gaps. This topic was reviewed in 2011 (Williams, 2011) but with new guidance and reports, and an ever-increasing demand without increasing resources, it seems a good time to revisit the same topic. This article will also include an overview of the problems and challenges encountered in caring for older people with diabetes. It will look at the benefits and disadvantages associated with team working. Finally, the article will address some particular challenges and describe how team working can improve the outcome for some of our most vulnerable patients.

Overview of older people with diabetes
Diabetes is the most common long-term condition affecting older people. In 2015 the prevalence of diabetes was 8% in England, 7.1% in Scotland and 9.6% in Wales amongst the general population (Public Health England, 2015). The prevalence shows a clear correlation to increasing age as this percentage rises to 16.9% in the population of people over 75 (Public Health England, 2015) and 20% a decade later (Sinclair, 2009). Diabetes prevalence is estimated to increase by 1% every decade (Public Health England, 2015). Older people now represent the largest sector of the population with the disease (Sinclair, 2009). Life expectancy is increasing and with an ageing population the number of older people with diabetes is rising, so the demand on services can only increase. Many older people with diabetes are able to live independently, but for some there are increasing challenges of frailty, comorbidities and social isolation. Additionally, there may be complications of diabetes present. Dementia is a particular challenge for healthcare professionals managing older people with diabetes; its prevalence is recorded as 1 in 25 in the 70–79 age group rising to 1 in 6 in the over 80 age group, with numbers estimated to rise exponentially by 2050 (Alzheimer’s Society 2013).

Diabetes management should always be patient-centred. Outcomes should be individualised and focus on improving the quality of life, while maintaining the physical and mental status of the person with diabetes. Rising expectations of healthcare includes an increased desire for patients, carers and families to be included in all decision making. The Commissioning Diabetes Services for Older People document (NHS Diabetes, 2010) endorses developing collaborative networks to promote service development to improve both social care and clinical outcomes for this group. The person with diabetes and their relatives or carer, must be involved in the management planning and decisions about his or her diabetes care (NHS Diabetes, 2009).

Older people with diabetes should have access to prompt expert advice, and should have good awareness of where and how to access this care (NHS Diabetes, 2009). The often multiple comorbidities experienced by older people mean that they should have frequent review of their management and early intervention if they are unwell.

Overview of team working
The Francis Report (Francis, 2013) recognised the importance of good team working in delivering safe care. Healthcare is often provided by “teams”, especially when managing care for older, or more complex, patients. Adair (2009) defines a team as a group of people working interdependently to achieve a common goal. Frequently, DSNs are providing care and management plans for older people with complex needs that also require the support of community nurses, social services and voluntary groups. A helpful description of effective teamwork that summarises the type of collaborative working required for older people with diabetes recognises that it is a dynamic process involving two or more healthcare professionals with complementary backgrounds and skills, sharing common health goals, and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care (Xyrichis and Ream, 2008). This is accomplished through interdependent collaboration, open communication and shared decision-making, and generates value-added patient, organisational and staff outcomes (Craig and McKeown, 2015).

A group of people working together does not necessarily constitute a team. Pseudo teams have been described where groups of people working together may have different goals and outcomes and have different managers (West and Lyubovnikova, 2012).

The NHS Five Year Forward View (NHS England, 2014) recognises that among other challenges, supporting and caring for frail older people is a particular challenge to the NHS. It plans to support the frail older people living in care homes (NHS England, 2014). The document recognises that services cannot meet the current demand so new, more efficient, effective ways of working must be developed to engage patients, carers and health and social care services in an integrated collaborative working relationship (NHS England, 2014). Integrated primary and acute care systems are advocated (NHS England, 2014), but the GP would continue to have responsibility for coordinating and overseeing their patients.

Demand, efficiency and funding are driving NHS England to look for new ways of working to ensure a sustainable NHS.

The King’s Fund has recognised that while public perceptions of healthcare are good, this is not the same for social care. Therefore, effective team working to deliver the best care to older people with diabetes requires a concerted effort and planning. Healthcare professionals working in diabetes are often employed by different providers, with differing goals to those working with older people, so the challenge is to work collaboratively and to embrace team working.

Benefits of team working
When multidisciplinary teams are working together successfully healthcare is improved, patient satisfaction is enhanced, care is improved through innovation and staff satisfaction improved. The consequences of this are that staff feel valued, so are retained and stress levels are reduced (West, 2013).

In a study of surgical patients in four UK hospitals, Borrill et al (2001) also identified similar benefits of effective team working. Additionally, the researchers found that there were fewer hospital admissions, errors were reduced and mortality rates improved. The study found that the greater number of professional groups represented in the multidisciplinary team the higher the levels of innovation (Borrill et al, 2001).

Sharing of ideas is conducive to innovative care, where teams will feel confident and supported to explore and try new ideas. It also provides an opportunity for clinical supervision and clinical governance, which can be a model for safer care. Effective team working improves patient safety and reduces errors (Baker et al, 2005).

Members of an effective team are committed to achieving the common goal and take personal responsibility for the team achieving that goal (Katzenbach and Smith, 1993). Team members’ behaviour and attitudes have a major influence on the ability of the team to achieve their goals (Mohrman et al, 1995). The importance of team members taking responsibility and being mutually accountable  for their behaviour and how they collaborate with their team members to achieve their common goal cannot be over estimated (Katzenbach and Smith, 1993; Mohrman et al, 1995).

Disadvantages of team working
Successful team working does not just happen; it takes time and constant effort to remind all team members of the common goal or vision. This should never be assumed and should be revisited frequently (Craig and McKeown, 2015). Good communication is essential and all information and sharing of ideas must be clearly understood.

When teams are not working effectively
In situations when teams are not working effectively, patient safety is compromised and, unfortunately, we have seen this happen in high profile cases. The Francis Report (Francis, 2013) recognised what happens when team working breaks down and recommends effective team working to improve care. In addition to compromised safety, precious resources are wasted through poor or fragmented care, services are not used appropriately, and those with the greatest need may not receive timely and appropriate care.

Among older people with diabetes, it is evident that some have poor access to the correct services or may receive it too late. Teams working in isolation can result in harm coming to the people with diabetes as services may not be designed in a patient-centred way and the care provided is often fragmented.

Furthermore, given how quickly the condition of some older people with multiple pathologies can change, services need to be able to respond to these changes in a timely fashion in order to provide access to services and care. Often teams working in isolation will not be sustainable as they are not robust.

How can teams work more effectively?
Effective leadership is essential for a team to function successfully and without it the team will be weak and unproductive. Within our everyday working groups, we need to practice these strategies to ensure we have the most effective team working relationship possible before we can reach out to form teams with other groups.

Teams need to be built, but team working is not an observer role; team members need to be committed to the vision of sharing the same goals. Teams go through different stages of development (Adair, 2009). Initially the team forms; this “forming” has to happen following any change in personnel. This initial stage is then followed by a period of “storming” where ideas are shared. The penultimate stage is “norming” where the culture of the team is developed before the final period of “performing” the assignment of the team.

Pastoral leadership is under recognised but is a vital part of ensuring all team members feel valued. This, in turn, maintains team morale and increases staff retention. Individual wellbeing is interconnected with the team wellbeing and contributes to fostering trust and openness within the most effective teams (Craig and McKeown, 2015).

Mickan and Rodger (2005) have identified the principles of good team working. They endorse:

• Having a common purpose with measurable goals.
• Effective leadership.
• Good communication.
• A good team spirit where team members enjoy working together and are committed to the team.
• Mutual respect among team members, which promotes a willingness to share knowledge and learning and to raise concerns.

Multidisciplinary teams may only be “pseudo teams”, which refers to a group of people working together but not collaboratively. They may be managed by different people who have differing professional goals, and boundaries may be unclear (Craig and McKeown, 2015).

Attitudes can be a barrier to effective team working. There should be no place for poor attitudes when we are all trying to provide the best care for our patients.

DSNs are well placed to work with commissioners to ensure services commissioned and provided meet the needs of older people with diabetes. Furthermore, good networks are valuable in working together and improving innovation in successful teams. Systems and pathways should be robust, aiming to maximise our current resources by providing the right services so that the right patients are in the right place. We should review our services regularly to ensure that we are providing the services our commissioners finance, that we are good stewards of our resources and that services are sustainable. This, in turn, can protect resources for our patients.

Teams without walls (Royal College of Physicians, Royal College of General Practitioners and Royal College of Paediatrics and Child Health, 2008) describes collaborative primary and acute working to provide the best care closer to home. Better care will reduce duplication of services while identifying any gaps. Effective team working fits well with this document. We must look beyond the geography to identify the barriers to good team working. Between different groups, such as health and social care, semantics can cause a problem so we need to communicate clearly using words and avoiding abbreviations. Modern communication technology should be made available in order  to improve communication between the multidisciplinary team. However, it is vital that all technology is secure and that confidentiality is not compromised. Frequently, team members are based in different locations, so video conferencing may be a more efficient use of time than travelling to hold a multidisciplinary team meeting. The best and most appropriate method of communicating can be easily identified by simply asking all team members what is best for them.

Given the complexities of managing comorbidities in older people with diabetes, the multidisciplinary team should be involved in planning and delivering individualised care to this patient group (NHS Diabetes, 2010). DSNs should work collaboratively with community nurses, GPs and social services to ensure an older person has a management plan that is realistic. The plan should have individualised goals and targets, with the aim of reducing the risks of both acute and chronic complications to ensure the patient is kept safe.

To conclude, for healthcare professionals to be good stewards of care resources, we need to be using these resources wisely. All the evidence supports effective team working as being the most successful way of achieving this. To this end, we need to cultivate successful team working, practise the strategies in our own teams and learn together how effective team working can improve care within current resources.